New Patient Form (ALL patients to complete)

CONFIDENTIAL PATIENT INFORMATION

Please note that your information is saved as you enter it.

Welcome to our practice. Our aim is to provide you with the best possible healthcare. Please complete all sections and read the Personal & Health Information Consent section at the end of this form. If you have any queries, please speak to one of our team members or Dr Foti.

Personal Details

    Medicare Details

    Do you have Private Health Insurance? Please select:

    Concession Card

    Privacy

    Do you consent to communication being sent to your family doctor or GP?

    General Practitioner's details (only complete this section if your GP was not your referring doctor)

    Are you happy for information to be given to your next of kin over the phone?

    Referral Source

    What is the reason for being referred to Dr Foti Sofiadellis?

    How did you hear about Dr. Foti Sofiadellis?

    MEDICAL QUESTIONNAIRE

    Medical History

    Have you ever experienced/undergone any of the following:

    If yes to diabetes, how is it controlled:

    Have you ever been treated for, or diagnosed with (tick if applicable):

    Are you currently a smoker?

    Do you have Allergies


    Medications

    Do you take any blood thinning medications, such as:


    Surgery

    Have you had any previous surgery?


    PHOTOGRAPHY CONSENT

    Clinical photos may be taken at your consultation and will form part of your clinical record. Images will be accessible to our staff for clinical purposes. Photos are stored in a secure server, compliant with the Australian Privacy Principles.

    For the purpose of teaching other health professionals such as doctors, nurses and associated students?
    YesNo

    In scientific publications e.g. articles in medical journals?
    YesNo

    To educate other patients, within our clinics?
    YesNo

    To educate patients on our website
    YesNo

    To educate patients on our social media accounts
    YesNo

    If you have ticked yes to any of the above and have any special requests with regards to how your photos are displayed or used, please list them below:

    These photos are stored in a secure server in compliance with the Australian Privacy Principles.

    They will be accessed by clinic staff and will not be sold or transferred to any other entity for purposes that have not been agreed to.

    Declaration: I grant permission for photographs of me to be used in the formats indicated above. I am at least 18 years of age, have read and understand the foregoing statement, have not been offered inducements to provide permission, and am competent to execute this agreement.

    AI Technology Consent


    PRIVACY

    Personal and Health Information Consent

    We respect your right to privacy and take our privacy obligations seriously. We comply with the Australian Privacy Principles, found under the Privacy Act 1988 (Cth). Our Privacy Policy can be obtained by requesting a copy from reception or from our website.

    We require your consent to collect personal information and health information about you. Please read this information carefully, and sign where indicated below.

    We collect information from you for the primary purpose of providing you with our healthcare services. We require you to provide us with your personal and health information and your full medical history so that we may provide our services to you. We will also use the information you provide in the following ways:

    • To appropriately manage our practice, including undergoing conduction audits and accreditation processes, managing billing and training staff.

    • To effectively communicate with third parties, including Medicare Australia, private health insurers, government departments, and other practitioners involved in your healthcare.

    During the post-operative period, if you have any post-operative complications, you may choose to send us questions or clinical photos for your nurse and Dr. Foti to review. In signing this form and choosing to transmit images or questions to us via email or mobile phone post-operatively, you acknowledge that these images may be transmitted to relevant clinicians via their devices (phones, iPad, email) for them to urgently review for post-surgical care as required.

    Patient Signature:


    Address

    The Avenue Private Hospital
    42 The Avenue
    Windsor
    Melbourne
    3181

    Contact

    Contact Number: (03) 7067 9688
    Fax Number: (03) 7046 6822
    Secure messaging for health professionals:
    Healthlink EDI: drfotios

    hours

    Monday - Friday 9am - 6pm

    social media

    Copyright © Dr Foti Sofiadellis